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4 Introduction and general approach to pain
No text of the brevity and practicality envisioned for this book could be
sufficiently comprehensive to cover all possibly acceptable approaches. By
making specific recommendations when evidence may be poor, conflicting,
or absent, authors will necessarily be somewhat subjective, and there will
inevitably be room for disagreement. Finally, however, clinicians must make
decisions about the patients in front of them. This book aims to help users to
do just that.
n Becoming comfortable with treating pain
Knowledge of analgesics should be a core area for our practice – up to 70% of
ED patients register with a primary complaint of pain. 1 Unfortunately, pain
education in medicine lags behind other areas. Many physicians graduate
from medical school with almost no training in pain management or analgesic
use. Attitudes such as opiophobia accompany us as we enter training and
are often reinforced by the training we receive. 2 Lack of knowledge and, even
more importantly, lack of understanding leave us unprepared. We often do
not recognize how our own cultural and moral beliefs can negatively impact
on patient pain management. For instance, when emergency physicians
were surveyed about the incidence of addiction among sickle cell patients
suffering from vaso-occlusive crises, 53% felt that more than 20% of patients
were addicted, although the actual addiction rate is less than 2%. 3 Such
beliefs can only be corrected if we learn how to differentiate drug-seeking
behavior derived from oligoanalgesia – as is the case with sicklers – from
similar, but not identical, behavior seen with addicts. It is only with such
knowledge that our comfort level can improve, while our distrust of patients
seemingly always in severe pain can diminish.
A nurse once said to me, “The patients always say their pain is 10/10, how
can we believe them?” The answer is often so obvious as to be invisible: why
come to an ED if pain is minimal? Every elderly patient we see in the ED is ill,
but we do not infer that all elderly people are sick. Similarly, although a large
portion of society suffers from chronic pain, most people do not. Our practice
sees patients at their worst. They are in pain, afraid, and ill or injured. Let us not
ever forget that as we apply the excellent advice seen in the following pages.